and other personnel not involved in direct patient care from daily work activities left workers on their own to resolve problems. At hospitals characterized by second-order problem solving, either nurse managers were a strong presence on the floor, or there was a designated person available to provide guidance and support to nurses (Tucker and Edmondson, 2002). The researchers concluded that “reducing the degree to which managers are available to front-line staff can be a loss for improvement efforts, especially when workers are already overburdened by existing duties” (Tucker and Edmondson, 2003:10).

The researchers identified several countermeasures to first-order problem solving to enable organizational learning. First, managers must be available to staff nurses for at least a portion of all shifts. The researchers observed that the presence of managers increased the likelihood of their being informed of problems occurring on the unit, thus enabling them to investigate and intervene with systemic solutions. Managers also serve as role models for system-level thinking, encouraging nurses to think of second-order solutions. Second, management needs to create a “fair and just” work environment (discussed in Chapter 7) that encourages workers to feel secure in reporting both errors and problems so system performance can be enhanced (Tucker and Edmondson, 2003). Also, if workers are to engage in identification and elimination of systemic problems, this activity should be an explicit part of their job description (Tucker et al., 2002), and they should receive training in its application (Tucker and Edmondson, 2002). Finally, management needs to act on reported problems with second-order solutions so workers will have an incentive to continue to identify these opportunities for learning and improvement (Tucker and Edmondson, 2003).

Recommendations to Promote Evidence-Based Management Practices

To address the deficiencies discussed above in nurses’ work environments with respect to the application of the five management practices introduced in this chapter, the committee offers the following two recommendations:

Recommendation 4-2. Leaders of HCOs should take action to identify and minimize the potential adverse effects of their decisions on patient safety by:

  • Educating board members and senior, midlevel, and line managers about the link between management practices and safety.

  • Emphasizing safety to the same extent as productivity and financial goals in internal management planning and reports, and public reports to stakeholders.



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